Risk Adjustment Coordinator
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
JOB SUMMARY
The Risk Adjustment Coordinator will assist with all reporting required by regulatory bodies or vendors that involves Risk Adjustment and any internal reports to demonstrate efficacy of the program and internal controls. The primary responsibility of this role is to support the centralized medical record collections for RADV and Risk Adjustment as required by federal statute and ensure compliance. Additionally, this role supports the team with scheduling of meetings, documenting of outcomes, facilitates the development of articles for newsletters/other communications, and other special projects to support the Risk Adjustment team.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Supports the centralized collection and submission of medical records to ensure compliance with federal and state regulatory requirements. Develop and manage a tracking system to monitor medical records requests, follow up on outstanding requests, process invoice submissions, and ensure timely follow-up to meet project deadlines.
Collaborates with cross-functional teams to enhance workflow processes, optimize document management, and support abstraction training and education. Assists in communicating status updates, providing feedback, and identifying areas for improvement based on strengths and weaknesses observed during task reviews.
Support the design and implementation of projects that highlight service and clinical quality improvements or identify opportunities for enhancement, in collaboration with Community stakeholders. Assist in preparing for internal and external meetings, while fostering strong, positive relationships with Community leadership, cross-functional departments, and delegated entities.
Actively contributes to the achievement of departmental goals, as identified in the Department's annual business plan, including specific departmental process improvement plans and other duties as assigned.
Reports to Position Title: Manager, Risk Adjustment
QUALIFICATIONS:
Education/Specialized Training/Licensure:
High School Diploma required
Bachelor's degree is preferred, ideally in Healthcare, Business, Health, or a related field; equivalent work experience will be considered preferred.
Work Experience (Years and Area):
- Minimum of one (1) year of healthcare experience with a relevant degree, or three (3) or more years of experience without a degree required.
- Experience in clinical documentation improvement preferred.
Management Experience: NA
Preferred: 2-5 years of management experience
Software Proficiencies:
Required.
Proficient in Microsoft Office Suite, including Word, Excel, Outlook, and PowerPoint
Familiar with standard office equipment, such as PCs, copiers, fax machines, and telecommunications equipment
Preferred.
Knowledge of medical coding systems, including ICD-10, HCPCS, and CPT
Excellent written and verbal communication skills
Strong interpersonal and relationship-building abilities
Solid understanding of ACA, Medicaid, and Medicare programs